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College  ol  $i)pgicians;  anb  burgeons! 

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CONTRIBUTION 


HYDROLOGICAL  TREATMEN 


m 


BRIGHT'S  DISEASES. 


DrT  A.  W.  De  roaldes, 

Resident  Physician,  Waukesha  Springs,  Wisconsin. 


Read  before  the  New  Orleans  Medical  and  Surgical  Ass'n. 


Reprint  from  New  Orleans  Medical  and  Surgical  Journal. 


SEW  ORLEANS: 
L.  GRAHAM,   STEAM  BOOK  PRINTER.   127  GRAYIER  ST., 

18  79. 


CONTRIBUTION 


Hydrological  Treatment  of  Bright's  Diseases. 

By   DR.   A.  W.   db  EOALDES,   Resident  Physician, 
Waukesha  Springs,  Wisconsin. 

Read  before  the  New  Orleans  Medical  and  Surgical  Association. 

In  bringing  the  discussion  to  bear  upon  Bright's  diseases, 
our  confrere  and  friend  Dr.  Loeber  has  chosen,  with  great  pro- 
priety, I  think,  to  limit  the  wide  field  of  albuminuria,  which  is 
too  vast  to  run  over  in  one  evening.  Limited  as  the  question 
may  be,  it  still  affords  room  for  different  views. 

]S"o  one  will  dispute  that,  in  some  cases  of  albuminuria,  the 
disease  is  entirely  constituted  by  a  renal  lesion,  as,  for  exam- 
ple :  Albuminuria  resulting  from  exposure  to  cold,  or  again 
cantharidian  nephritis.  But  what  constitutes  Bright's  dis- 
eases"? There  lies  the  question.  For  some  physicians  it  is 
merely  and  primarily  a  local  renal  lesion ;  for  others,  and  this 
seems  to  be  a  more  philosophical  view,  Bright's  diseases  are  in 
their  very  incipiency  general  affections,  constitutional  disor- 
ders, dyscrasise,  as  scrofula,  gout,  rheumatism,  syphilis,  of 
which  albuminuria,  at  the  start,  is  only  a  symptom.  The  ex- 
cretion of  albumen  may  in  these  conditions  be  the  initial  phe- 
nomenon without  being  accompanied,  in  the  beginning  at  least, 
by  any  lesion  of  the  kidneys.  Albumen  may  be  excreted  by 
these  organs  as  sugar  is.  The  only  difference  between  diabetes 
and  incipient  albuminuria  of  Bright's  diseases,  lies  in  the  ex- 
creted substances.  If  it  be  sugar,  a  hydro-carbon  possessed  of 
dialysable  properties,  the  excretion  will  be  affected  without 
producing  any  local  disorder  in  the  parenchyma  or  stroma  of 
the  kidney ;  if,  on  the  contrary,  it  be  albumen,  a  colloid  sub- 
stance, the  kidney  will  soon  become  affected.  This  transuda- 
tion of  albumen  is  accompanied  by  renal  congestion ;  if  it  be 
moderate,  the  disease  may  run  a  very  slow  course.  There  are 
cases  of  Brightic  albuminuria,  which  may  have  a  very  long 


duration,  ten,  fifteen,  twenty  and.  more  years.  I  was  consulted 
two  months  ago,  by  a  medical  gentleman,  who  has  been  passing 
albumen  ever  since  1874.  It  is  only  in  the  last  two  years  that 
the  examination  of  his  urine  has  revealed  the  presence  of 
casts,  and  it  is  only  since  this  comparatively  short  time  that 
his  general  health  has  become  affected.  Last  summer,  at  the 
springs,  I  had  under  my  charge  a  lawyer  from  Paris  ;  his  phys- 
ician. Dr.  (rubier,  stated  in  his  letter  to  me,  that  our  patient 
had  been  passing  albumen  ever  since  1853.  This  slow  progress 
of  the  disease  is  witnessed  only  in  such  constitutions  as  are 
free  from  a  diathetic  influence.  Take,  for  instance,  a  scrofu- 
lous, a  syphilitic,  a  rheumatic,  or  a  gouty  patient,  whose  con- 
stitution shows  a  tendency  to  the  evolution  of  morbid  products 
of  a  retrogressive  character.  The  congestion,  in  such  cases, 
will  soon  lead  to  the  formation  of  neoplasms,  to  the  poliferation 
of  new  cellular  elements,  etc.  Simple  albuminuria  will  then  be 
of  very  short  duration  and  will  soon  result  in  Brightic  diseases. 

But  I  shall  not  stop  to  enquire  the  cause,  by  reason  of  which 
albumen  escapes  from  the  blood  to  mingle  with  the  urine.  Is 
it  the  kidney  which  just  becomes  diseased,  or  is  this  organ 
secondarily  affected  ?  Must  we,  on  the  contrary,  look  for  the 
incipiency  of  the  malady  in  a  functional  disorder  of  the  liver 
and  stomach  ?     Or  is  it  the  blood  which  is  primarily  affected  ! 

1  particularly  desire  to-night  to  direct  your  attention  to  a 
few  special  points  of  therapeutics  of  Blight's  diseases.  In  con- 
tending with  these  affections,  you  must  with  me  have  observed 
the  striking  discrepancy  in  the  results  obtained  in  the  treat- 
ment of  hospital  patients,  as  against  those  obtained  in  the 
treatment  of  patients  of  a  better  class — the  former,  as  a  rule, 
are  extremely  discouraging,  whilst  the  latter  afford,  at  times,  a 
reasonable  degree  of  satisfaction.  I  am  aware  that  the  dis- 
crepancy may,  in  a  measure,  be  due  to  the  fact  that,  in  the 
former  instance,  we  are  called  upon  to  see  our  patients  when 
the  disease  has  reached  an  advanced  stage.  But  are  they  not 
also  measurably  due  to  the  tact  that  we  are,  unfortunately, 
limited  almost  exclusively,  I  may  say,  to  the  use  of  pharmaco- 
d\  mimic  agents  I 


♦Medical  hydrology,  climatology,  hygiene  and  electricity  now 
seem  to  take  precedence  in  the  treatment  of  chronic  diseases. 
And  I  am  inclined  to  the  belief  that  in  Bright's  diseases  you 
will  often  obtain  more  satisfactory  results  if,  with  due  regard 
to  the  indications  furnished  by  the  etiology  of  the  affection, 
you  give  a  greater  weight  when  possible  to  these  powerful  mod- 
ificators.  I  have  had  occasion  during  the  past  few  years  to 
obtain  some  happy  results  by  the  use  of  medical  hydrology 
applied  to  Bright's  diseases.  You  will,  therefore,  before  I  pro- 
ceed further,  permit  me  to  condense  a  few  observations  which 
will  enable  me  to  draw  some  conclusions  in  regard  to  the  use 
of  this,  therapeutical  method. 

OBSERVATION  I.— CASE  OF  CHRONIC  PARENCHYMATOUS 
NEPHRITIS. 

Mr.  C,  a  gentleman  about  47  years  of  age,  was  directed  by 
his  physician,  Dr.  L'heritier,  of  Paris,  to  follow  a  water  cure  at 
the  calcic  springs  of  Yittel.  Mr.  C.  had  an  attack  of  cholera 
in  1871,  and  of  rheumatism  in  1872.  With  these  exceptions, 
his  health  has  been  good  up  to  1877,  when  he  began  to  lose 
flesh  and  strength  without  any  apparent  cause.  In  September 
of  the  same  year,  he  suffered  from  intense  dyspeptic  troubles, 
with  marked  dysphagia  and  shortness  of  breath.  In  March, 
1878,  got  wet  in  a  very  heavy  rain,  and  had  a  spell  of  acute 
desquamative  nephritis,  followed  by  two  relapses,  at  short  in- 
tervals. Fever,  general  pains  over  the  body,  with  marked  sen- 
sibility over  the  lumbar  region,  gastric  symptoms,  oedema  of 
legs  and  thighs,  urine  heavily  loaded  with  albumen,  were 
among  the  characteristic  symptoms.  Patient  arrived  at  the 
springs  June  5th.  His  urine  presents  an  acid  reaction,  it  is 
frothy  and  clear,  except  at  the  bottom  of  the  vessel,  where  a 
white  yellowish  sediment  is  observed.  His  urine  of  the  day 
contains  5  grammes  18  centigr.  (a  little  over  80  grains)  of  albu- 
men ;  the  one  of  the  night,  3.13  gr.  (about  49  grains) ;  area, 
15.30  gr.  (about  228  grains).  Microscopical  examination  of 
sediment  shows  numerous  large,  dark  colored  crystals  of  uric 
acid,  broad  granular  casts  in  large  number,  a  few  narrow,  pale, 

*  Medical  hydrology  treats  of  the  internal  and  external  use  of  water  in  disease,  and 
comprises  mineral  springs,  sea-bathing,  douches  of  all  sorts,  medicated  baths,  Turkish 
and  Russian  baths,  etc. 


slightly  curved  casts  with  some  renal  opaque  epithelial  cells 
adherent.  ]STo  fatty  globules  nor  any  waxy  cylinders.  Blood 
corpuscles  numeration  gives  3,490,000.  Weight  of  the  body 
152  pounds. 

Patient  was  advised  to  drink  from  8  to  12  glasses  of  mineral 
water,  to  take  one  bath  a  day  of  one  hour's  duration  at  39° 
Centigr.,  followed  by  frictions  and  kneading,  and  a  hot  revul- 
sive douche  at  42°  Centigr.  of  five  minutes  over  the  lunibar 
region. 

On  the  8th  day  the  quantity  of  albumen  is  reduced  to  1.90 
gr.  (about  30  grains)  in  the  day.  and  1  33  gr.  (about  20  grains) 
in  the  night's  urine.  On  the  25th  day  the  urine  shows  but  a 
trace  of  albumen  and  contains  but  a  few  hyaline  casts.  Upon 
departure,  July  12th,  37th  day  of  the  water  cure,  the  urine  is 
entirely  free  from  albumen  and  casts.  The  numeration  of  blood 
corpuscles  gives  3,900,000.  Weight  of  the  body  161  pounds. 
The  microscopical  examination,  which  was  repeated  several 
times  during  treatment,  has  shown  a  disappearance  of  the 
casts  parallel  with  the  diminution  of  albumen,  until  at  last,  a 
careful  micro-chemical  test  revealed  the  absence  of  both.  The 
quantity  of  urine,  which  during  treatment  was  increased  to 
1700  C.  0.,  has  fallen  back  to  1290  C.  C,  upon  departure; 
specific  gravity=1017  and  urea=19  grammes  (about  289  grains.) 

OBSERVATION  II.— CASE  OF  INTERSTITIAL  NEPHRITIS. 
Mr.  E.,  a  merchant,  14  years  of  age,  was  prescribed  by  Dr. 
Gubler,  of  Paris,  a  water  course  at  the  Springs  of  Yittel, 
where  he  arrived  June  20, 1876.  When  29  years  of  age,  patient 
had  an  attack  of  double  urethro-orchitis,  which  has  left  as  a 
sequela  some  weakness  about  the  genital  organs.  His  father 
was  subject  to  gout,  and  died  in  epileptiform  tits.  Mr.  R.,  him. 
self,  has  been  attacked  three  or  four  times  with  articular  gout, 
the  last  time  in  May,  1874.  During  past  1  or  5  years,  patient 
has  noticed  in  his  urine  a  frequent  deposit  of  a  yellow-pinkish 
liu.'.  On  January  10, 1876,  was  laid  in  lied  for  a  fortnight  with 
erratic  pains  of  the  whole  body,  fever,  epistaxis,  bronchitis, 
Lumbar  pains  greater  on  the  right  side.  His  sputa  were 
streaked  with  blood.  Urine  was  diminished  in  quantity, 
highly    colored,    albuminous    and  containing  few   casts,    but 


wholly  deprived  of  its  deposit  of  urates  or  uric  acid.  This 
acute  spell  subsided  gradually,  and  patient  was  finally  relieved 
by  the  appearance  in  his  urine  of  a  copious,  brick-colored, 
sandy  deposit.  However,  he  never  since  enjoyed  his  ordinary 
health,  and  his  urine  has  kept  albuminous. 

Condition  upon  arrival  at  the  springs :  The  skin  is  dry  and 
branny,  appetite  poor,  thirst  normal,  digestion  torpid  and  sleep 
impaired.  Patient  experiences  a  very  uncomfortable  sensation 
of  prickling  about  the  inferior  extremities.  Slight  oedema  of 
the  ankles  and  feet ;  frequent  micturition.  Passes  1600  C.  0. 
of  a  cloudy,  acid  urine,  containing  22  grammes  of  urea,  1.75 
gr.  of  phosphates,  7  gr.  of  chlorides,  2  gr.  of  albumen.  Uric 
acid  and  urates  are  diminished.  There  is  a  slight  hypertrophy 
of  the  heart,  but  no  valvular  lesion,  no  palpitations.  Bespira- 
tory  murmur  normal.  Blood  corpuscles=3,600,000.  Micro- 
scopical examination  shows  numerous  granulo-fatty  cylinders, 
some  few  hyaline  casts,  some  others  dotted  over  with  fine  dark 
granulations.     Bare,  waxy-like  casts. 

Patient  was  directed  to  drink  12  to  14  glasses  of  mineral 
water  a  day,  1  glass  of  Pulna  water  every  fourth  day,  to  over- 
come costiveness.  Tepid  bath  at  37°  €.,  followed  by  frictions 
and  kneading  of  the  whole  body.  Hot  revulsive  douche  at 
12°  C,  over  the  lumbar  region. 

About  the  7th  day,  albumen  began  to  diminish  ;  on  the  20th 
day,  the  quantity  was  reduced  to  0  gr.  80  centigr  *  on  the  37th 
day,  when  patient  left  the  springs,  a  trace  of  albumen,  some 
hyaline  cylinders  and  a  very  few  granulo-fatty  casts  only  are 
to  be  found  upon  close  research.  During  the  first  week  of 
treatment,  the  quantity  of  urine  passed  daily  was  increased 
from  1000  C.  C.  to  2300  C.  C,  and  was  heavily  loaded  with 
uric  acid.  General  neuropathic  symptoms  have  subsided  ;  the 
sleep  is  improved  and  patient  no  longer  experiences  his  trouble- 
some cerebral  lassitude.  Numeration  of  blood  corpuscles  gives 
4,200,000.  Patient  has  gained  o  pounds;  and  a  slight  exercise 
will  promote  perspiration. 

OBSERVATION   III.— CASE  OF  CHRONIC  PARENCHYMATOUS 
NEPHRITIS. 
Mr.  H.,  aged  38  years,  a  banker,  arrived  at  La  Bourboule 
Arsenical  Thermal  Springs,  June  26,   187s,  sent  by  his  Paris 


physician,  Prof.  Chauffard.  Has  attended,  him  during-  1  years. 
In  his  letter,  after  rapidly  going  over  the  history  of  the  case, 
lie  remarks  that  Mr.  H.  was  forced  to  abandon  Constantinople 
in  1 874,  on  account  of  obstinate  intermittent  fevers,  accom- 
panied with  enlargement  of  the  spleen.  The  type  of  fever  was 
at  first  modified  by  the  change  of  climate,  and  patient,  after  13 
months,  was  entirely  free  of  malarial  attacks.  His  health,  not- 
withstanding, was  far  from  being  restored  to  its  normal  stand- 
ard. Patient  remained  anemic,  although  iron,  quinine  and 
strychnia  were  administered.  Complained  of  general  weak- 
ness, of  palpitations,  accompanied  with  repeated  attacks  of 
bronchitis,  characterized  by  intense  dyspncea,  mostly  noctur- 
nal, and  by  sputa  occasionally  tinged  with  blood.  Sleep  dis- 
turbed by  cough  and  frequent  desire  to  micturate.  Urine  clear 
and  frothy.  A  close  investigation  led  Dr.  Chauffard  to  diag- 
nose the  case  as  one  of  incipient  parenchymatous  nephritis 
from  malarial  poisoning.  During  two  years,  various  treatments 
were  uselessly  employed,  the  disease  following  a  progressive 
course. 

At  last  Dr.  C.  decided  upon  removing  his  patient  from  the 
confined  and  hot  sn aimer  atmosphere  of  Paris,  and  he  was  or- 
dered to  resort  to  a  water  cure,  with  the  hope  that  the  change 
of  climate  and  the  use  of  arsenical  springs  would  help  to  re- 
build bis  general  constitution  and  put  a  check  to  the  pulmonary 
and  renal  congestions.  Upon  arrival  at  the  springs  Mr.  H.  is 
in  the  following  condition  :  General  appearance  is  bad,  whether 
tin's  be  the  result  of  his  journey  or  not;  mucous  membranes 
are  unusually  pale,  the  skin  is  dry,  and  the  seat  of  a  marked 
epithelial  desquamation  (pityriasis),  marked  emaciation,  pa- 
tient weighing  137  pounds,  waxy  appearance  of  the  teguments. 
Liver  and  lungs  are  normal,  spleen  slightly  enlarged.  The 
eyelids  are  somewhat  bloated.  Patient  is  troubled  with  fre- 
quenl  micturation  at  night  (8  to  10  times).  Quantity  of  daily 
urine  1410  G.  C.  specific  gravity =1001).  Night  urine  contains 
3  gr.  <>!>  ceutigr.,  and  day  urine  about  0  gr.  19  centigr.  of  albu- 
men. Quantity  of  urea  exceedingly  small=ll  gr.  70  centigr. 
Phosphates  and  chlorides  are  in  normal  proportions.  Micro- 
scopical examination  shows:  Numerous  and  thick   crystals  of 


uric  acid,  granule-fatty  casts  with  oil  globules,  numerous  nar- 
row cylinders  with  fine  granulations,  some  broad  waxy  casts 
and  degenerated  epithelial  cells  with  irregularly  defiud  edges. 
Mr.  H.  is  advised  to  rest  a  week  before  beginning  treatment.  On 
the  third  day  I  am  called  to  see  him.  Patient  is  laboring  under 
an  attack  of  severe  bronchitis,  with  slight  pulmonary  oedema. 
Heart  is  normal,  but  rather  impulsive.  Feet  cedematous. 
Next  day  the  oedema  has  reached  the  scrotum  ;  thighs  and  legs 
are  considerably  swollen.  Quantity  of  urine  diminished  to  900 
C.  0.  Sp.  gr=1014. 

Patient  feels  pretty  well  on  the  tenth  day  of  this  attack,  with 
the  exception  of  the  anasarca  of  the  inferior  extremities.  The 
swelling  is  such  that  patient's  weight  has  been  raised  from  137 
to  172  pounds.  Obtaining  no  result  from  purgative  plan,  ad- 
vised him  to  begin  at  once  hydropathic  treatment,  consisting 
in  hot  air  baths — Turkish  baths — which  were  administered  for 
a  period  of  two  weeks  (one  bath  every  other  day).  Patient 
gradually  reached  a  temperature  of  176°  F.  As  much  as  1200 
grammes  of  water  (nearly  2£  pounds)  were  abstracted  from  the 
system  in  one  bath  ;  urine  passed  in  24  hours,  averaging  950  C. 
O.  After  the  eighth  bath,  patient  was  nearly  relieved  of  his 
anasarca;  his  weight  fell  down  to  130  pounds,  or  1  pouud  less 
than  he  weighed  upon  arrival. 

The  hydromineral  treatment  was  then  instituted,  and  patient 
advised  to  drink  from  2  to  4  glasses  of  mineral  water.  Baths 
at  39°  C.  were  also  ordered,  and  were  followed  by  a  hot  revul= 
sive  douche  applied  over  the  splenic  and  lumbar  regions. 

This  treatment,  kept  up  for  a  month,  brought  on  a  most  re- 
markable improvement.  The  condition  of  the  patient  upon  de- 
parture, August  18th — that  is,  92  days  after  his  arrival,  was 
as  follows :  Appetite  restored ;  sleep  interrupted  but  once  or 
twice  for  micturation  ;  patient  has  made  frequent  excursions  in 
the  mountains  with  comparative  ease ;  the  functions  of  the  skin 
are  normal;  no  cedema  ;  complexion  darker,  but  still  retaining 
an  anaemic  taint ;  only  a  trace  of  albumen  in  the  urine.  Casts 
are  few  in  number,  broad  and  granulo -fatty,  no  waxy  cylinders 
nor  any  oily  globules.  Some  renal  epithelial  cells  with  natural 
dull  tint.     The  quantity  of  urea  has  been  raised  up  to  15  gram- 


mes,  and  amount  of  urine  daily  excreted=1370  C.  C.  lias 
gained  15  pounds.  Patient  left  the .springs  after  being  advised 
ro  sojourn  in  the  south  of  France  or  Italy  during  winter,  and 
to  return  next  summer  to  the  springs. 

Had  occasion  to  1 1 ear  from  Mr.  H.,  through  his  physician. 
He  lias  wii  tered  at  ('amies,  and  during  January  has  drank  the 
transported  waters.  Has  followed,  otherwise,  no  special  treat- 
ment, but  exercised  in  the  open  air.  Has  had  no  recurrence  of  his 
brouchitic  attacks :  his  general  health,  which  is  very  good,  has 
allowed  him  to  enjoy  ordinary  life.  His  urine  still  shows  a 
trace  of  albumen,  detectable  only  with  Heller's  test.  The 
microscope  shows  the  presence  of  a  few  broad  granulo-fatty 
easts,  with  degenerated  epithelial  cells. 

OBSERVATION    1 V.-  CASE  UF  CHRONIC  PARENCHYMATOUS 
NEPHRITIS. 

George  Brungard,  27  years  of  age,  entered  Charity  Hospital 
March  8,  1879.  A  year  ago,  patient  then  living  in  Arkansas, 
was  attacked  with  malarial  fever,  of  a  tertian  type.  In  October, 
after  exposure  to  rain  and  cold,  was  seized  with  rigors,  followed 
by  lever,  nausea,  and  pains  in  the  lumbar  region,  and  swelling 
of  the  inferior  extremities. 

Upon  admission,  patient  says  he  has  been  unable  to  leave  his 
bed  for  the  past  two  months  on  account  of  excessive  weakness. 
Mucous  membranes  and  teguments  show  a  waxy  hue,  face  is 
bloated,  appetite  impaired,  bowels  loose.  Inferior  extremities 
and  scrotum  are  the  seat  of  considerable  serous  effusion. 
Heart  normal,  but  spleen  is  enlarged.  Patient's  sleep  is  often 
interrupted  by  cough,  due  to  slight  (edema  of  the  lungs. 

Patient  is  put  under  observation  for  a  few  days.  The  urine 
is  very  pah-,  frothy  and  acid  ;  average  about  2000  0.  0.  a  day, 
with  a  sp.  gr.  of  HKI7.  It  contains  a  large  quantity  of  albu- 
men :  7  gr.  '.»<»  v<^y.  Urea=14  gr.  75  cgr.  At  the  bottom  of  the 
jar,  there  is  an  opaline  deposit  of  formed  elements,  which, 
under  the  microscope,  proves  to  be  composed  of  small  and  nar- 
row hyaline  casts,  with  very  few  granular  cylinders,  and  some 
renal  epithelial  cells,  with  a  number  of  uric  acid  crystals. 
Patient  was  ord<  fed   L5  drops  of  dilute  phosphoric  acid  three 


9 

times  a  clay,  and  10  to  12  glasses  of  Waukesha  water  (Crescent 
Spring).  From  March  18th  to  April  28tb,  microscopical  exam- 
ination  and  analysis  of  urine  were  made  daily  ;  from  these  tab- 
ular records,  I  condense  the  following :  Urine  rapidly  became 
ueutral,  with  marked  tendency  to  ammoniacal  decomposi- 
tion after  being  voided. 

March  21st,  Day  urine=1490  C.  C,  with  sp.  gr.==1010. 

Night  urine=1090  C.  C,  with  sp.  gr.=1009. 
April  7th,  Day  urine=600  C.  C,  with  sp.  gr.=1018. 

Night  urine=1240  C.  0.,  with  sp.  gr.=1009. 
Albumen  passed  in  24  hours=4  gr.  22  centigr. 
Microscopical  examination  shows  a  few  hyaline  casts,  and 
renal  epithelial  cells,  with  amorplius  earthy  phosphates. 

April  13th,  Day  urine=400  C.  C,  with  sp.  gr.=1022 

Night  urine=879  C.  C,  with  sp.  gr.=1011. 
No  casts,  and  but  a  few  renal  epithelial  cells  and  amorphous 
phosphates. 

April  26th,  Day  urine=700  C.  C,  with  sp.  gr.=1018. 

Night  urine=900  C.  C,  with  sp.  gr.=1012. 
Quantity  of  albumen  in  24  hours=2  gr.  29  centigr. 

Microscopical  examination  shows  a  complete  absence  of  casts. 
Urea=18.10  gr.  During  the  time  (38  days)  patient  has  been 
under  treatment,  he  has  had  five  attacks  of  malarial  fever,  for 
which  quinine  was  administered.  The  fever  seemed  to  have 
no  other  effect  upon  the  urine  except  in  diminishing  its  quantity 
and  deepening  its  color.  Notwithstanding  this,  general  con- 
dition of  patient  steadily  improved,  appetite  increased.  Bowels 
have  become  regular  and  digestion  is  normal.  All  liquid  effu- 
sion has  been  removed.  His  complexion  looks  healthier,  and 
auscultation  reveals  no  abnormal  sounds.  Patient  has  been 
able  during  the  last  two  weeks  to  assist  the  nurse  of  the  ward 
in  the  discharge  of  his  duties.  Was  last  seen  on  May  14th. 
Has  had  another  attack  of  fi-ver,  but  his  general  condition  con- 
tinues very  good.  Quantity  of  urine  about  normal,  so  are  its 
reaction  and  color.  No  casts,  but  still  contains  about  two 
grammes  of  albumen.     Urea=17.80  gr. 

I  will  now  be  permitted  to  draw  some  conclusions,  which 
seem  to  me  justified  by  the  study  of  these  observations. 


10 

1st.  Thei  e  is  a  marked  diminution  of  tlie  albuminuria  as  a 
consequence  of  the  diuresis  produced  by  the  use  of  calcic  min- 
eral waters.  The  renal  congestion,  instead  of  being  exaggerated, 
has  on  the  contrary  been  diminished  by  this  diuretic  influence. 
This  result  corroborates  the  statement  of  01.  Bernard,  based 
on  actual  experiment,  namely  :  the  disgorgement  of  glands  by 
increased  functional  activity.  In  observation  No.  3,  arsenical 
waters  having  no  marked  effect  on  diuresis,  we  have  to  look 
elsewhere  to  explain  their  eflicacy.  The  explanation  lies,  I 
think,  in  the  undoubted  properties  of  arsenic  to  diminish  con- 
gestion by  its  influence  on  the  vaso-motor  nerves.  We  all 
know  the  good  results  attained  with  arsenic  in  the  treatment 
of  congestive  headache,  neuralgia,  pulmonary  congestion,  etc 
Besides  this  explanation,  arsenic  seemed  to  have  filled  a  pre- 
cise indication  furnished  by  the  fact  of  previous  malarial  intox- 
ication, and  the  use  of  hot  air  baths  by  stimulating  the  func- 
tions of  the  skin  to  their  utmost  capacity,  certainly  had  the 
effect  of  diminishing  the  tension  of  the  blood  in  the  renal  blood 
vessels. 

2d.  In  all  four  observations  the  diminution  of  the  quantity 
of  albumen  has  been  progressive  and  very  nearly  parallel  with 
the  diminution  of  the  gravity  of  casts  and  epithelium  of  renal 
origin.  I  will  remark  also  that,  as  the  worst  form  of  cylinders 
disappeared  or  were  modified,  there  seemed  to  have  been  a 
species  of  substitution  of  hyaline  casts. 

3d.  The  general  health  and  strength  of  these  four  patients 
were  remarkably  improved  by  this  course  of  treatment.  The 
numeration  of  blood  corpuscles  was  resorted  to  in  two  in- 
stances, and  showed  a  marked  increase.  Corresponding  to  this 
an  increase  in  weight,  ranging  from  five  to  fifteen  pounds  was 
also  obtained,  except  in  case  4,  where  this  observation  was 
neglected  for  want  of  scales. 

I  feel  consequently  justified  in  saying  that  the  treatment  has 
fulfilled  what  should  be  considered  the  principal  indications  in 
Bright's  diseases,  viz  : 

1st.  To  uphold  the  constitution  and  rebuild  the  impoverished 
general  conditions. 


11 

2d.  To  diminish,  if  not  to  suppress  the  congestion  of  the 
kidneys. 

3d.  To  clear,  and  if  possible  to  modify  the  tubuli  nriniferi. 

Before  closing,  allow  me  to  direct  your  attention  to  the  influ- 
ence gout  holds  in  the  production  of  interstitial  nephritis.  It  is 
such  that  the  gouty  kidney  is,  with  English  writers,  synony- 
mous with  contracted  kidney.  This  etiological  influence  is  well 
exemplified  by  Case  II.  It  is  in  those  cases  that  the  calcic 
waters  of  Vittel  in  France,  Wildungen  in  Germany,  Capon  and 
Poland  in  this  country,  will  prove  efficacious.  Those  of  Buffalo 
and  the  Waukesha  Crescent  Springs  containing,  in  addition, 
bicarbonate  of  lithia,  are  specially  indicated.  Their  first  effect 
is  to  render  the  urine  alkaline,  and  then  to  favor  the  elimina- 
tion of  uric  acid — accumulated  in  the  blood — under  the  form 
of  urate  of  lithia,  the  most  readily  soluble  combination  of  uric 
acid.  It  frequently  occurs,  when,  in  gout,  or  in  Bright's  dis- 
eases, the  urinary  secretion  is  scanty,  that  uric  acid,  and  even 
urate  of  soda,  will  be  deposited  in  the  tubuli  uriniferi,  in  the 
shape  of  what  Bayer  has  termed  microscopic  gravel.  In  these 
cases,  these  diuretic  calcic  and  lithia  mineral  wateis,  filtering 
rapidly  and  in  abundance  through  the  kidneys,  will  have  a  sort 
of  lixiviatiug  result,  and  thus  favor  the  solution  of  these  infarc- 
tions, open  and  keep  free  the  tubuli  uriniferi.  It  is  useless  to 
insist  upon  this  beneficial  effect,  for,  in  a  contracted  or  gouty 
kidney,  it  is  preparing  the  way  for  uremic  poisoning,  not  to 
avail  ourselves  of  every  possible  means  to  prevent  those  tubuli, 
which  are  still  sound,  and  through  which  the  urea,  uric  acid, 
and  extractive  matters  are  excreted,  from  being  blocked  and 
clogged  by  this  microscopical  gravel. 

I  will  lastly  recall  the  influence  of  chronic  malarial  poison- 
ing in  the  etiology  of  Bright's  diseases.  Case  ~$o.  Ill  and  ]So. 
IV  exemplifies  this  point,  and,  although  I  have  had,  this  win- 
ter, in  my  wards  of  the  Charity  Hospital,  three  cases  of  chronic 
parenchymatous  nephritis,  in  which  the  disease  was  clearly  at- 
tributable to  malaria,  I  am  not  prepared  as  yet  to  assert  that, 
in  the  majority  of  such  cases,  we  will  be  more  apt  to  meet  with 
parenchymatous  than  with  interstitial  nephritis. 


12 

In  those  cases  we  will  have  to  administer  quinine,  even  it' 
the  patient  is  tree  from  paroxysm.  But  when  it  has  led  to  un- 
doubted disorder  of  the  kidney,  we  will,  I  think,  lind  in  arsenic, 
hydropathy,  mineral  springs,  with  change  of  climate,  lnodifica- 
tors  which  will  act  in  a  more  direct  manner  upon  the  lesion, 
provided,  of  course,  it  be  not  too  far  advanced. 

If  Bright's  diseases  present  themselves  in  a  decided  scrofu 
lous  constitution,  we  may,  with  advantage,  advise  a  course  of 
treatment  by  the  saline  alkaline  and  iodo-bromine  waters,  as 
Kxeutzuach,  Hombourg,  Darkheim  in  Germany,  Solies,  Brides, 
in  France,  Saxon  in  Switzerland,  and  St.  Catherine's  Wells  and 
Caledonia  Springs  in  this  country.  If,  on  the  other  hand,  our 
patient  is  subject  to  rheumatism,  or  has  had  syphilis,  if  the 
kidneys  are  but  recently  involved,  and  we  believe  rheumatism 
or  syphilis  has  had  an  etiological  influence,  we  will  then  find- 
in  thermal  waters,  of  the  indeterminate  class,  as  Hot  Springs 
of  Arkansas,  or  of  the  sulphur  class,  as  those  of  Virginia,  a 
valuable  adjuvant. 


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